Tuesday, July 22, 2008

A recent journal article pointed out the widely-reported danger of smokers using beta-carotene, a natural source (provitamin) of vitamin A, as part of their multivitamins. 1 In this meta-analysis (as in common in such analyses) the researchers have neglected to consider pre-existing dietary and serum levels of this nutrient, making their claim to control by placebo inadequate to properly isolate this variable. In fact, this failure to determine the effects of beta-carotene at a dose-dependent plasma level – and by neglecting to measure total beta-carotene intake along with the relevant synergistic antioxidants associated with it, as opposed to simply measuring supplemental intake - raises serious questions about the validity of these results. 2
There is also legitimate scientific debate over the use of trans versus cis forms of this provitamin that may affect the way it is used by our bodies in vivo that dispute whether all forms are equal, which most studies simply do not address (including this meta-analysis). 3
Regarding beta-carotene safety little has been satisfactorily resolved, and the negative studies have been vigorously disputed for these and other reasons. For example, researchers have previously noted in the Journal of the National Cancer Institute that beta-carotene has been shown to not affect the risk of oxidative DNA damage in male smokers, despite its reputation as an antioxidant. But neither did the provitamin A prove to cause oxidative DNA damage. 4
It has become apparent to numerous observers that simply measuring supplementation of beta-carotene is not a good predictor of serum levels or of risk, and that a low level of total antioxidant intake may be a more valid marker in this regard. In fact, the dietary level of several antioxidants has been shown to be an independent predictor of plasma beta-carotene, especially in moderate alcohol drinkers. A recent study reports, "This may explain, at least in part, the inverse relationship observed between plasma beta-carotene and risk of chronic diseases associated to high levels of oxidative stress (i.e., diabetes and CVD), as well as the failure of beta-carotene supplements alone in reducing such risk." 2
As the authors (Tanvetyanon, et al) of this current analysis have themselves noted, the Physicians Health Study compared the effects of taking 50 mg of supplemental beta-carotene (over 83,000 IU) every other day to a placebo in 22,071 US male physicians aged 40-84 and found no adverse health effects over a 12-year study period. 5
Likewise, the Women’s Health Study of 39,876 health professionals found no significant difference on lung cancer rates when looking at the effects of 50 mg of beta-carotene administered on alternate days over 2+ years plus a 4-year follow up period, using forms and dosing similar to the Physician’s Health Study to achieve very high serum levels of beta-carotene. 6
In a third study used in the current meta-analysis, The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group (ATBC), an antioxidant study in Finland was halted early because of a widely reported small increase in cancer rates among male smokers taking beta-carotene that were only possibly linked to that nutrient. 7 Headlines associated this supplement with cancer risk. Despite objections that the study was flawed, beta-carotene use dropped. This study continues to be widely cited and believed, despite the researchers’ own statements that the results were most likely due to chance.
A later analysis published in July 2004 took another look at that same Finnish smokers study’s data, but now taking into account total antioxidant intake, which should have cleared away some of the scientific controversy over beta-carotene safety. The smokers’ risk of getting lung cancer was inversely associated with total antioxidants in the diet, with more total antioxidants resulting in fewer cancers. 8 In this study a composite antioxidant index was generated for each of the 27,000 men over 14 years. The calculated amounts of carotenoids, flavonoids, vitamin E, selenium and Vitamin C were compared to actual lung cancer rates, with a clear result: a combination of antioxidants lowered lung cancer risk in male smokers. Properly reviewed, beta-carotene was not the culprit; low antioxidant status was the more relevant factor affecting cancer rates, and supplementation with a single antioxidant supplement simply failed to create enough improvement to avert deaths related to oxidative factors. Perhaps the supplementation with beta-carotene was simply a case of "too little, too late", rather than a root cause of a slightly higher lung cancer rate in those smokers.
It is notable that Tanvetyanon et al included the ATBC study but failed to even reference the later Wright et al study that largely refuted the alleged harms of beta-carotene shown in ATBC, which were shown to be more likely due to low levels of total antioxidant intake than to excessive beta-carotene intake. This later review of ATBC should be a cautionary tale concerning the lack of proper controls in nutrient studies, especially as compounded by the use of meta-analysis, and should have alerted the current authors to that all-too-common mistake in nutrient study design.
Indeed, another large study has noted that high carotenoid intake, confirmed by measures of plasma, was associated with lower mortality rates among the elderly over a ten year period. 9 This model measured results of consuming both supplements and foods, not solely supplement input, and when combined with plasma levels should therefore be regarded as a far more robust type of science for measuring vitamin effects than a meta-analysis of simply supplementation. As in the long-term Physicians Health Study, there was no observable risk of lung cancer noted in this report.
The fourth study used in the current meta-analysis used very high doses of both beta-carotene (30 mg, equal to 50,000 IU) plus 25,000 IU of pre-formed vitamin A. 10 These amounts are extremely high; the Upper Limit for vitamin A is 10,000 IU, though there is no official Upper Limit for beta-carotene because of its historic safety record. The amounts of beta-carotene used in the eye vitamins were high only because the authors selected solely formulas designed for eye health that typically provide more beta-carotene than ordinary multivitamins. This distinction is not clear in their calling such formulas "multivitamins", because that name is typically given to full-spectrum formulas containing a full range of the essential vitamins with minerals, not system-specific formulas like those sold for eye health. Such formulas have proved to be beneficial in maintaining eye health and the combination of antioxidants have been stronger antioxidants than beta-carotene, which is potentially a pro-oxidant at times and could thus be used more safely – and effectively - in combination with other antioxidants. 11 That being said, eye formulas with more milligrams of lutein than beta-carotene are probably better formulated than ones with very high beta-carotene because of their competition for absorption.
Most importantly, the authors have not shown why they assume that "multivitamin" use would be associated with the supposed risks of beta-carotene used singly, even if those risks for the solo provitamin are assumed to be true. Nor have they adequately demonstrated the alleged dangers of taking eye formula supplements, or even the danger of lung cancer rates increasing in those taking mixtures of beta-carotene combined with other antioxidant nutrients.
In the case of multivitamins most studies have shown overwhelmingly positive effects, such as one report evidencing reduced infections in nursing homes with vitamins over placebo (73% vs. 43%). Intervention was with a multivitamin containing beta-carotene. Infection-related absenteeism was higher in the placebo group than in the treatment group (57% vs. 21%). Perhaps most importantly, 93% of participants with diabetes mellitus reported an infection versus only 17% of those receiving supplements. 12 These huge reductions in potentially serious infections among our elderly citizens should be measured against the relatively slight and mostly theoretical risk of increased lung cancer rates associated with beta-carotene supplementation.
A study reported in the Journal of the National Cancer Institute looked at death rates in a population given multivitamins or other nutrients. 13 After supplements were given for 5.25 years in the general population trial of 30,000 people, significant reductions in total [relative risk (RR) = 0.91] and cancer (RR = 0.87) mortality were observed in subjects receiving beta-carotene, alpha-tocopherol, and selenium combined. The same researchers reported on a subgroup of 3,318 persons with esophageal Dysplasia (a precursor to esophageal cancer) that was given either a multiple vitamin-and-mineral supplement or a placebo for 6 years. In this portion of the trial, small reductions in total (RR 0.93) and cancer (RR = 0.96) mortality were observed but were not significant. In any case, no increase in cancer rates was noted in the group taking multivitamins; there was actually a possible small benefit in terms of reducing this risk. The participants getting the multivitamin took a daily beta-carotene capsule along with two multivitamin tablets. This was a group of subjects at high risk of getting throat cancer. 14-15
It is a leap of faith to assume that a single nutrient would have identical effects to a combination of nutrients without substantial supporting evidence, which is still lacking; confounded by conflicting evidence and multiplying variables in meta-analyses. Since nutrients are both synergistic and present in the diet, it is important to factor those known variables into a proper study design. All too often, researchers do not consider this fundamental difference between drug and nutrient research and unwittingly introduce extra variables that undermine their conclusions. 16

This current meta-analysis of 4 studies - only one of which unquestionably shows a slight increase in lung cancer risk but does not actually measure isolated beta-carotene risk; two others are well-designed and robust studies looking at serum levels of those taking a high dose of beta-carotene but show no increased risk in lung cancer rates, and the fourth has been largely shown to be moot by a later and more complete re-analysis of the data - does not support the hypothesis that beta-carotene increases rates of lung cancer and that multivitamins are therefore dangerous. Thus, there is no sound basis in the current review for suggesting that warning labels may be needed for multivitamins or eye health supplements containing beta-carotene along with other nutrients that have been shown in well-designed studies to help protect the eyesight – and independence - of our aging population.
REFERENCES:

Tanvetyanon T, Bepler G. Beta-carotene in multivitamins and the possible risk of lung cancer among smokers versus former smokers: a meta-analysis and evaluation of national brands. Cancer. 2008 Jul 1;113(1):150-7. PMID: 18429004

Valtueña S, et al. The total antioxidant capacity of the diet is an independent predictor of plasma beta-carotene. Eur J Clin Nutr. 2007 Jan;61(1):69-76. Epub 2006 Jul 12. PMID: 16835597 [Supported by the European Community IST-2001–33204 'Healthy Market', the Italian Ministry of University and Research COFIN 2001 and the National Research Council CU01.00923.CT26 research projects.]

Wednesday, July 09, 2008

Memory and Age
By Neil E. Levin, CCN, DANLA
The most important things for an older person to consider in protecting against minor memory loss – often attributed to “aging” – include:
· Maintain at least a nominal physical activity level to keep circulation and body functions at optimal levels.
· Take a good multivitamin to assure minimal levels of essential nutrients. Too many elders fail to eat properly or to get adequate levels of B vitamins and other key nutrients associated with proper cognitive function. Also, the elderly don’t absorb nutrients from food as efficiently, making supplementation even more important.
· Don’t forget to eat meals. Often, single, divorced or widowed seniors fail to eat regular meals on schedule. This creates nutrient deficiencies that complicate their ability to maintain physical and mental health.
· Don’t overeat on processed, high fat, high sodium foods such as fast foods to “compensate” for poor eating habits.
· Take foods and supplements that are rich in antioxidants. Oxidative damage is clearly associated with many of the conditions that affect mental, as well as physical, capabilities in older people. This includes negative changes to the brain itself; and also the nervous system, the eyes and joints.
· Use vitamin D, which may be in your multivitamin or calcium supplement, to compensate for the lack of direct sunlight on skin. This essential vitamin also helps with immunity, cardiovascular health and bone health.
· If your dietary habits are reasonably good and you still want some more natural aids for brain and memory function, consider a brain nutrient formula.
Of course, college age is a time when many students want to use brain nutrients to maximize their learning and recall, especially for tests. Many adults then coast through adulthood until they reach their 40’s or 50’s and start to get a little forgetful. By then, they should already be examining their diet, lifestyle and stress levels to consider whether they may need additional nutritional support for their mental functions. If they wait until things get bad - in their 60’s, 70’s or later - it may be too late to preserve their memories and mental acuity.
Basic brain nutrients are multivitamins, lecithin and fish oil. Antioxidants will protect the brain’s structures and functions throughout adulthood. Magnesium, an essential mineral that is deficient in 90% of Americans, helps to reduce toxic effects of chemicals on neurons; as do antioxidants such as vitamin E, tocotrienols, and vitamin C.
People will usually hint at the need, or ask about Ginkgo or look at the section. We’re not the family, friends or work colleagues that people try to hide symptoms from…after all; we are the ones that perfect strangers often disclose their bowel habits and other normally hidden quirks to. Speaking in user-friendly but technical structure-function language will often make the discussion less personal and more scientific, removing much of the emotional content of the health issue.
Phosphatidyl Serine is a phospolipid compound derived from soy lecithin that plays an essential role in cell membrane composition and intercellular communication. Phosphatidyl Serine is a major structural component of neural membranes where it assists in the conduction of electrical impulses and facilitates the activity of neurotransmitters involved in learning, memory and mood. These properties make Phosphatidyl Serine formulas ideal basic supplements for the support of cognitive function. There is enough evidence of the safety and efficacy of PS for the FDA to have issued a qualified health claim for it.
DMAE is known primarily as a precursor to choline and acetylcholine (chemicals in the brain responsible for nerve transmissions and cognitive function), and has been used most predominantly to improve memory and focus while stimulating neural activity. Many researchers believe that it may serve an anti-aging function by increasing the body’s capacity to produce acetylcholine – a deficiency commonly associated with memory loss.
Scientific research has demonstrated that Ginkgo Biloba Extract has antioxidant activity in in vitro studies and thus may aid in maintaining healthy brain and memory function.
The insulating myelin sheaths that protect the brain, spine and thousands of miles of nerves in the human body are almost two-thirds Lecithin. Lecithin is composed of many different components, including Choline, Inositol, Linoleic Acid, Phosphatidyl serine, fatty acids and triglycerides. These valuable constituents of Lecithin are vital for the proper functioning of many metabolic processes.
And let’s not forget the benefit of DHA and fish oil. Fish oils are typically molecularly distilled and tested to be free of screened for the absence of potentially harmful levels of contaminants (i.e. mercury, heavy metals, PCB's, dioxins, and other contaminants). DHA is utilized in forming the brain and nerves.
And last but not least, antioxidants and magnesium are very helpful in protecting brain structures and may be useful in preventing some of the feared declines associated with aging brains. For example, vitamin C actually pumps glutamates out of neurons.

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About Me

Neil E. Levin, CCN, DANLA is a nationally board-certified clinical nutritionist with a Diplomate in Advanced Nutritional Laboratory Assessment. He is a professional member of the International & American Associations of Clinical Nutritionists.
Neil is a nutrition educator and a dietary supplement formulator.
Neil is a member of the Scientific Council of the national Clinical Nutrition Certification Board and is on the board of directors of the Mid-American Health Organization (MAHO), the Midwest regional affiliate of the National Products Association (NPA). In July, 2008, Neil was named an NPA Industry Champion, "an award given to people who have made notable individual contributions to industry above and beyond what is expected to achieve commercial success".
Neil is the immediate past president and Program Chair of the American Nutrition Association (americannutritionassociation.org).
Neil is frequently published or quoted in magazines, newspapers, and scientific journals and has been on numerous radio and television news programs. Follow me on Twitter: neilelevin